- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.82 / $355.62 / $585.38
| Professional | | $245.82 | $355.62 | $585.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.25 / $386.52 / $707.51
| Professional | | $268.25 | $386.52 | $707.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.55 / $458.79 / $808.86
| Professional | | $361.55 | $458.79 | $808.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.00 / $4,049.00 / $5,510.00
| Facility | | $1,812.00 | $4,049.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.76 / $566.20 / $876.74
| Professional | | $313.76 | $566.20 | $876.74 |